PACKRAT 13 # matches
Which of the following factors in patients with chronic venous insufficiency predisposes
them to development of skin ulcers?
A. Increased intravascular oncotic pressure
B. Leakage of fibrinogen and growth factors into the interstitial space
C. Decreased capillary leakage
D. Inherited deficiency of protein C - Answer (u) A. Decreased intravascular oncotic
pressure can cause swelling
(c) B. Leakage of fibrinogen and growth factors into the interstitial space, leukocyte
aggregation and activation, and obliteration of the cutaneous lymphatic network can
predispose a patient to skin ulcers
(u) C. Increased capillary leakage causes venous insufficiency.
(u) D. Inherited deficiency of protein C predisposes patients to thrombosis.
A 26 year-old monogamous female presents with cyclic pelvic pain that has been
increasing over the last 6 months. She complains of significant dysmenorrhea and
dyspareunia. She uses condoms for birth control. On physical examination her uterus is
retroverted and non-mobile, and she has a palpable adnexal mass on the left side. Her
serum pregnancy test is negative. Which of the following is the most likely diagnosis?
A. Ovarian cancer
B. Endometriosis
C. Functional ovarian cyst
D. Pelvic inflammatory disease - Answer (u) A. It is important to consider ovarian cancer
in a patient with a pelvic mass however, ovarian cancer usually occurs in older women
over age 55 and patients are often asymptomatic until the disease is more advanced
(c) B. With endometriosis, the uterus is often fixed and retroflexed in the pelvis. The
palpable mass is an endometrioma or "chocolate cyst". The patient with endometriosis
also often has dysmenorrhea, dyspareunia, and dyschezia.
(u) C. Functional ovarian cysts occur from ovulation and usually are not symptomatic.
(u) D. With PID the patient will have abdominal tenderness, adnexal tenderness,
cervical motion tenderness and an elevated temperature.
At what age does the first tooth usually erupt in an infant?
A. 2-4 months
B. 6-8 months
C. 10-12 months
D. 14-16 months - Answer (u) A. See B for explanation.
(c) B. The first tooth in an infant to erupt is the central incisor at the average age of 6-8
months.
(u) C. See B for explanation.
(u) D. See B for explanation.
A 7 year-old boy wets the bed on most nights. Which of the following is the preferred
pharmacological agent to decrease the incidence of bed wetting episodes?
A. Imipramine (Tofranil)
B. Phenytoin (Dilantin)
C. Pramipexole (Mirapex)
,PACKRAT 13 # matches
D. Hyoscyamine (Urised) - Answer (c) A. Imipramine is an anti-cholinergic and when
given before bedtime has been shown to decrease the incidence of bed wetting.
(u) B. Phenytoin is an anticonvulsant and is not used in enuresis.
(u) C. Pramipexole is a dopamine agonist used in the treatment of restless leg
syndrome.
(u) D. Hyoscyamine is an anti-spasmodic used to treat overactive bladder.
A newborn is being evaluated for perioral cyanosis while feeding associated with
sweating. Vital signs are rectal temperature, 37.8 degrees C (100 degrees F), blood
pressure 80/45 mmHg, pulse 180/min, and respirations 40/min. A grade 3/6 harsh
systolic ejection murmur with a single loud S2 is heard at the left upper sternal border.
Electrocardiogram (ECG) shows right ventricular hypertrophy with right axis deviation.
Chest x-ray shows a boot-shaped heart and decreased pulmonary vascular markings.
Which of the following is the most likely diagnosis?
A. Atrial septal defect
B. Total anomalous pulmonary venous return
C. Coarctation of the aorta
D. Tetralogy of Fallot - Answer (u) A. Although the murmur may be consistent with an
ASD with pulmonary hypertension the chest x-ray would not show decreased pulmonary
vascular markings. With a large left to right shunt large pulmonary arteries and
increased vascularity would be seen.
(u) B. The murmur for TAPVR is a soft systolic murmur at the left upper sternal border
with a split S2 in addition to a short mid-diastolic murmur at the low left sternal border.
(u) C. Cyanosis is usually not the presenting sign for coarctation of the aorta. Infants
may present with heart failure, ECG will show evidence of LVH.
(c) D. This is a common presentation for tetralogy of fallot.
Which of the following is considered to be the modality of choice for the identification of
a pituitary macroadenoma that is suspected on the basis of a visual field deficit?
A. Skull x-ray
B. PET scan
C. CT of the brain
D. MRI of the brain - Answer (u) A. Skull x-ray is not the modality of choice for the
identification of pituitary macroadenoma.
(u) B. PET scan is not the modality of choice for the identification of pituitary
macroadenoma.
(u) C. CT of the brain is not the optimal imaging technique for evaluation of the pituitary
stalk.
(c) D. MRI of the brain provides the best visualization of pituitary tumors.
A 2 year-old male presents with a four day history of fever and general malaise. On
examination the vitals reveal an oral temperature of 102 degrees F. The child appears
to have rubor on the trunk which started one day prior to this visit. Physical examination
reveals a maculopapular rash with defervescence. Which of the following is the most
appropriate management at this time?
A. Ibuprofen (Motrin)
,PACKRAT 13 # matches
B. Aspirin
C. Amoxicillin
D. Valacyclovir (Valtrex) - Answer (c) A. Motrin is indicated for management of the fever
in Roseola infantum caused by the herpesvirus.
(h) B. Aspirin is contraindicated in children for management of fever.
(u) C. Amoxicillin is not indicated for viral infections.
(u) D. Valacyclovir is indicated for Varicella-Zoster virus infection for decreasing the
incidence of varicella pneumonia only. In healthy children valacyclovir is not indicated
due to its marginal therapeutic benefit.
A 42 year-old female experiences pain on the plantar surface of her left foot in the area
of the third metatarsal head. The pain is associated with wearing tight shoes and is
relieved by removing shoes. Examination reveals a palpable mass and reproduction of
pain with deep palpation of the third intermetatarsal space. The patient has tried
wearing wider shoes with metatarsal cushions and taking NSAIDS but her symptoms
persist. What is the best therapeutic option at this point?
A. Casting of the involved foot
B. Physical therapy
C. Steroid injection
D. Surgical excision - Answer (u) A. Casting the foot in a patient with Morton's neuroma
is not effective therapy.
(u) B. Physical therapy has not been shown to be of benefit in treating Morton's
neuroma.
(c) C. Steroid injection is the treatment of choice for Morton's neuroma when
conservative measures fail.
(u) D. Surgical excision is recommended for treatment of Morton's neuroma only if
conservative measures and steroid injection have failed.
Which of the following is the most likely to develop into a persistent cough in the adult
patient?
A. Pertussis
B. Allergic rhinitis
C. Pharyngitis
D. Heart failure - Answer (c) A. Pertussis is suspected in patients with persistent cough
that lasts longer than 2-3 weeks. Allergic rhinitis, pharyngitis and heart failure are all
potential causes of acute cough.
(u) B. See A for explanation.
(u) C. See A for explanation.
(u) D. See A for explanation.
A 30 year-old patient presents with weight loss, diarrhea, and steatorrhea. Labs reveal
that the antiendomysial antibody (AEA) is positive. What is the most likely diagnosis?
A. Celiac sprue
B. Ulcerative colitis
C. Whipple's disease
, PACKRAT 13 # matches
D. Zollinger-Ellison syndrome - Answer (c) A. Celiac sprue is not only characterized by
these classic symptoms. The antiendomysial antibody has a 90-95% sensitivity and 90-
95% specificity for celiac sprue.
(u) B. Ulcerative colitis could be responsible for the symptoms mentioned however
antiendomysial antibody (AEA)would not be positive.
(u) C. Whipple's disease is an infectious disorder known to cause diarrhea and weight
loss. It also results in arthralgia and symptoms involving both the central nervous and
cardiac systems that are not easily missed due to their severity. Diagnosis involves
biopsies of the involved tissues looking for PAS-positive macrophages.
(u) D. Zollinger-Ellison syndrome (ZE) is a hypersecretory disorder. Diarrhea can occur
but will not generally be the predominant symptom.
A patient sustained a 6 cm laceration on his anterior tibia that was primarily closed in
the emergency department. What is the most appropriate time frame for removal of
these sutures?
A. 1-2 days
B. 3-5 days
C. 6-8 days
D. 7-14 days - Answer (u) A. See D for explanation.
(u) B. See D for explanation.
(u) C. See D for explanation.
(c) D. Suture removal is based upon the area of the body that was sutured. Facial
sutures are placed for 3-4 days, scalp sutures for 5-7 days, trunk sutures are placed for
6-8 days, and sutures on the extremity are placed for 7-14 days. Sutures on the
extremities can stay for longer periods of time if the area is under maximal tension.
A hospitalized patient is found with confirmed pulseless ventricular tachycardia. IV
access is obtained following the second shock given. Which of the following
medications is to be administered immediately?
A. Amiodarone
B. Magnesium
C. Atropine
D. Epinephrine - Answer (u) A. Antiarrhythmics are given after the third shock and
epinephrine has been administered.
(u) B. Magnesium is useful for torsades de pointes.
(u) C. Atropine may be used for asystole or a slow pulseless electrical activity (PEA)
rate.
(c) D. Epinephrine should be given as soon as IV access is obtained before or after the
second shock.
A patient with advanced AIDS complicated by toxoplasmosis presents with altered
mental status, recent onset of seizures, and focal neurologic deficits. Which of the
following diagnostic studies is most helpful?
A. Toxoplasma gondii antibody titers
B. CT scan of the brain
C. Lumbar puncture
Which of the following factors in patients with chronic venous insufficiency predisposes
them to development of skin ulcers?
A. Increased intravascular oncotic pressure
B. Leakage of fibrinogen and growth factors into the interstitial space
C. Decreased capillary leakage
D. Inherited deficiency of protein C - Answer (u) A. Decreased intravascular oncotic
pressure can cause swelling
(c) B. Leakage of fibrinogen and growth factors into the interstitial space, leukocyte
aggregation and activation, and obliteration of the cutaneous lymphatic network can
predispose a patient to skin ulcers
(u) C. Increased capillary leakage causes venous insufficiency.
(u) D. Inherited deficiency of protein C predisposes patients to thrombosis.
A 26 year-old monogamous female presents with cyclic pelvic pain that has been
increasing over the last 6 months. She complains of significant dysmenorrhea and
dyspareunia. She uses condoms for birth control. On physical examination her uterus is
retroverted and non-mobile, and she has a palpable adnexal mass on the left side. Her
serum pregnancy test is negative. Which of the following is the most likely diagnosis?
A. Ovarian cancer
B. Endometriosis
C. Functional ovarian cyst
D. Pelvic inflammatory disease - Answer (u) A. It is important to consider ovarian cancer
in a patient with a pelvic mass however, ovarian cancer usually occurs in older women
over age 55 and patients are often asymptomatic until the disease is more advanced
(c) B. With endometriosis, the uterus is often fixed and retroflexed in the pelvis. The
palpable mass is an endometrioma or "chocolate cyst". The patient with endometriosis
also often has dysmenorrhea, dyspareunia, and dyschezia.
(u) C. Functional ovarian cysts occur from ovulation and usually are not symptomatic.
(u) D. With PID the patient will have abdominal tenderness, adnexal tenderness,
cervical motion tenderness and an elevated temperature.
At what age does the first tooth usually erupt in an infant?
A. 2-4 months
B. 6-8 months
C. 10-12 months
D. 14-16 months - Answer (u) A. See B for explanation.
(c) B. The first tooth in an infant to erupt is the central incisor at the average age of 6-8
months.
(u) C. See B for explanation.
(u) D. See B for explanation.
A 7 year-old boy wets the bed on most nights. Which of the following is the preferred
pharmacological agent to decrease the incidence of bed wetting episodes?
A. Imipramine (Tofranil)
B. Phenytoin (Dilantin)
C. Pramipexole (Mirapex)
,PACKRAT 13 # matches
D. Hyoscyamine (Urised) - Answer (c) A. Imipramine is an anti-cholinergic and when
given before bedtime has been shown to decrease the incidence of bed wetting.
(u) B. Phenytoin is an anticonvulsant and is not used in enuresis.
(u) C. Pramipexole is a dopamine agonist used in the treatment of restless leg
syndrome.
(u) D. Hyoscyamine is an anti-spasmodic used to treat overactive bladder.
A newborn is being evaluated for perioral cyanosis while feeding associated with
sweating. Vital signs are rectal temperature, 37.8 degrees C (100 degrees F), blood
pressure 80/45 mmHg, pulse 180/min, and respirations 40/min. A grade 3/6 harsh
systolic ejection murmur with a single loud S2 is heard at the left upper sternal border.
Electrocardiogram (ECG) shows right ventricular hypertrophy with right axis deviation.
Chest x-ray shows a boot-shaped heart and decreased pulmonary vascular markings.
Which of the following is the most likely diagnosis?
A. Atrial septal defect
B. Total anomalous pulmonary venous return
C. Coarctation of the aorta
D. Tetralogy of Fallot - Answer (u) A. Although the murmur may be consistent with an
ASD with pulmonary hypertension the chest x-ray would not show decreased pulmonary
vascular markings. With a large left to right shunt large pulmonary arteries and
increased vascularity would be seen.
(u) B. The murmur for TAPVR is a soft systolic murmur at the left upper sternal border
with a split S2 in addition to a short mid-diastolic murmur at the low left sternal border.
(u) C. Cyanosis is usually not the presenting sign for coarctation of the aorta. Infants
may present with heart failure, ECG will show evidence of LVH.
(c) D. This is a common presentation for tetralogy of fallot.
Which of the following is considered to be the modality of choice for the identification of
a pituitary macroadenoma that is suspected on the basis of a visual field deficit?
A. Skull x-ray
B. PET scan
C. CT of the brain
D. MRI of the brain - Answer (u) A. Skull x-ray is not the modality of choice for the
identification of pituitary macroadenoma.
(u) B. PET scan is not the modality of choice for the identification of pituitary
macroadenoma.
(u) C. CT of the brain is not the optimal imaging technique for evaluation of the pituitary
stalk.
(c) D. MRI of the brain provides the best visualization of pituitary tumors.
A 2 year-old male presents with a four day history of fever and general malaise. On
examination the vitals reveal an oral temperature of 102 degrees F. The child appears
to have rubor on the trunk which started one day prior to this visit. Physical examination
reveals a maculopapular rash with defervescence. Which of the following is the most
appropriate management at this time?
A. Ibuprofen (Motrin)
,PACKRAT 13 # matches
B. Aspirin
C. Amoxicillin
D. Valacyclovir (Valtrex) - Answer (c) A. Motrin is indicated for management of the fever
in Roseola infantum caused by the herpesvirus.
(h) B. Aspirin is contraindicated in children for management of fever.
(u) C. Amoxicillin is not indicated for viral infections.
(u) D. Valacyclovir is indicated for Varicella-Zoster virus infection for decreasing the
incidence of varicella pneumonia only. In healthy children valacyclovir is not indicated
due to its marginal therapeutic benefit.
A 42 year-old female experiences pain on the plantar surface of her left foot in the area
of the third metatarsal head. The pain is associated with wearing tight shoes and is
relieved by removing shoes. Examination reveals a palpable mass and reproduction of
pain with deep palpation of the third intermetatarsal space. The patient has tried
wearing wider shoes with metatarsal cushions and taking NSAIDS but her symptoms
persist. What is the best therapeutic option at this point?
A. Casting of the involved foot
B. Physical therapy
C. Steroid injection
D. Surgical excision - Answer (u) A. Casting the foot in a patient with Morton's neuroma
is not effective therapy.
(u) B. Physical therapy has not been shown to be of benefit in treating Morton's
neuroma.
(c) C. Steroid injection is the treatment of choice for Morton's neuroma when
conservative measures fail.
(u) D. Surgical excision is recommended for treatment of Morton's neuroma only if
conservative measures and steroid injection have failed.
Which of the following is the most likely to develop into a persistent cough in the adult
patient?
A. Pertussis
B. Allergic rhinitis
C. Pharyngitis
D. Heart failure - Answer (c) A. Pertussis is suspected in patients with persistent cough
that lasts longer than 2-3 weeks. Allergic rhinitis, pharyngitis and heart failure are all
potential causes of acute cough.
(u) B. See A for explanation.
(u) C. See A for explanation.
(u) D. See A for explanation.
A 30 year-old patient presents with weight loss, diarrhea, and steatorrhea. Labs reveal
that the antiendomysial antibody (AEA) is positive. What is the most likely diagnosis?
A. Celiac sprue
B. Ulcerative colitis
C. Whipple's disease
, PACKRAT 13 # matches
D. Zollinger-Ellison syndrome - Answer (c) A. Celiac sprue is not only characterized by
these classic symptoms. The antiendomysial antibody has a 90-95% sensitivity and 90-
95% specificity for celiac sprue.
(u) B. Ulcerative colitis could be responsible for the symptoms mentioned however
antiendomysial antibody (AEA)would not be positive.
(u) C. Whipple's disease is an infectious disorder known to cause diarrhea and weight
loss. It also results in arthralgia and symptoms involving both the central nervous and
cardiac systems that are not easily missed due to their severity. Diagnosis involves
biopsies of the involved tissues looking for PAS-positive macrophages.
(u) D. Zollinger-Ellison syndrome (ZE) is a hypersecretory disorder. Diarrhea can occur
but will not generally be the predominant symptom.
A patient sustained a 6 cm laceration on his anterior tibia that was primarily closed in
the emergency department. What is the most appropriate time frame for removal of
these sutures?
A. 1-2 days
B. 3-5 days
C. 6-8 days
D. 7-14 days - Answer (u) A. See D for explanation.
(u) B. See D for explanation.
(u) C. See D for explanation.
(c) D. Suture removal is based upon the area of the body that was sutured. Facial
sutures are placed for 3-4 days, scalp sutures for 5-7 days, trunk sutures are placed for
6-8 days, and sutures on the extremity are placed for 7-14 days. Sutures on the
extremities can stay for longer periods of time if the area is under maximal tension.
A hospitalized patient is found with confirmed pulseless ventricular tachycardia. IV
access is obtained following the second shock given. Which of the following
medications is to be administered immediately?
A. Amiodarone
B. Magnesium
C. Atropine
D. Epinephrine - Answer (u) A. Antiarrhythmics are given after the third shock and
epinephrine has been administered.
(u) B. Magnesium is useful for torsades de pointes.
(u) C. Atropine may be used for asystole or a slow pulseless electrical activity (PEA)
rate.
(c) D. Epinephrine should be given as soon as IV access is obtained before or after the
second shock.
A patient with advanced AIDS complicated by toxoplasmosis presents with altered
mental status, recent onset of seizures, and focal neurologic deficits. Which of the
following diagnostic studies is most helpful?
A. Toxoplasma gondii antibody titers
B. CT scan of the brain
C. Lumbar puncture
